Nurse / Clinical Appeals

KMM Technologies, Inc.; Great Falls Crossing (VA); Remote; USD 65,000 - 85,000; Full time

Job summary

A leading healthcare organization is seeking a Clinical Appeals Specialist to manage and resolve member and provider disputes regarding adverse coverage decisions. The role requires strong analytical skills and clinical knowledge to formulate professional responses. Candidates should have a High School Diploma and clinical experience, with a preference for those holding a BSN/MSN degree. This remote position offers the opportunity to impact patient care through effective appeals management.

Qualifications

• 2 years medical-surgical or similar clinical experience.
• 2 years' experience in Medical Review or similar.

Responsibilities

• Investigates and analyzes written appeals from multiple sources.
• Organizes appeal cases for physician review and communicates decisions.
• Collaborates with Regulatory Agencies regarding complaints.

Skills

Communication

Critical Thinking

Analytical Skills

Problem-Solving

Customer Service

Education

High School Diploma

BSN/MSN Degree

Tools

Microsoft Office

Job description

Position: Nurse / Clinical Appeals

Location: Reston, VA #REMOTE

Duration: Long term

Job Description

• The Clinical Appeals Specialist completes research, basic analysis, and evaluation of member and provider disputes regarding adverse and adverse coverage decisions.
• The Clinical Appeals Specialist utilizes clinical skills and knowledge of all applicable State and Federal rules and regulations that govern the appeal process for Commercial lines of business to formulate a professional response to the appeal request.
• Education Level: High School Diploma
• 2 years medical-surgical or similar clinical experience OR 3 years' experience in mental health, psychiatric setting.
• 2 years' experience in Medical Review, Utilization Management or Case Management at or similar Managed Care organization or hospital preferred. BSN/MSN Degree.
• Knowledge and understanding of medical terminology, advanced level.
• Demonstrated knowledge of regulatory and accreditation requirements, understanding of appeals process and utilization management, and systems software used in processing appeals. Proficient level.
• Excellent verbal and written communication skills, strong listening skills, critical thinking and analytical skills, problem-solving skills, ability to set priorities and multi-task. Proficient level. Ability to effectively communicate and provide positive customer service to every internal and external customer.
• Knowledge of Microsoft Office programs. Proficient level.
• Excellent analytical and problem-solving skills to assess the medical necessity and appropriateness of patient care and treatment on a case-by-case basis, including issues pertaining to members with mental health treatment needs or those with substance disorders and addictions. Proficient level.
• Ability to research and analyze clinical records.
• Ability to prioritize work daily to maintain timeliness.
• Ability to review multiple platforms to determine needs.
• Ability to contact provider offices and determine needs for member's appeals.

Licenses/Certifications

• RN - Registered Nurse - State Licensure And/or Compact State Licensure
• CCM - Certified Case Manager
• LNCC - Legal Nurse Consultant Certified

Essential Functions

1. 35% Investigates, interprets, and analyzes written appeals and reconsideration requests from multiple sources including applicants, subscribers, attorneys, group administrators, internal stakeholders, and other initiators. Responds with original, complex, and technical letters, upholding corporate policies and decisions while meeting all State and Federal regulations and mandates.
2. 35% Organizes the appeal case for physician review by compiling clinical, contractual, medical policy, and claims information along with corporate and appellant correspondence. Formulates recommendations for disposition. Prepares the written case for review and, following the physician review, communicates the final decision to the member and providers, including an explanation of the final decision and all external appeal rights.
3. 25% Investigates, interprets, analyzes, and prioritizes appeal requests using nursing expertise and all available clinical information for both medical and behavioral health conditions, as well as medical policies, to determine if adverse decisions are appropriate. Collaborates with Independent Review Organizations and contracted Panel Physicians to obtain clinical opinions from physician specialists. Interacts with Regulatory Agencies and CMS regarding complaints.
4. 5% Maintains a current knowledge base of medical practices and procedures, including current terminology, procedures, and diagnostic entities related to medical, mental health, and substance abuse/addiction treatments.

Thanks & Regards,

• LAXMAN KMM Technologies, Inc. CMMI Level 2 | ISO 9001 | ISO 20000 | ISO 27000 Certified Tel: [phone] | Email: [e-mail]